Endovascular treatment of arterial steal secondary to dialysis fistula

Sir, In the literature, the treatment of an arterial steal syndrome in patients with dialysis fistula has been described to mainly concentrate on decreased or abolished blood flow through the arteriovenous shunt, or bypassing the fistula w1–4x. An important cause of the steal phenomenon in a limb distal to a dialysis fistula is, however, distal artery occlusive disease, reducing limb perfusion to a critical level. In our opinion, awareness of this is important as endovascular treatment of a distal arterial lesion could make surgical intervention unnecessary, thereby preventing morbidity and fistula loss. The two following cases are examples of this. Case 1. The first patient is a 78-year-old male who developed ischaemic rest pain in his right hand after a brachio-cephalic fistula was formed. A duplex scan showed a 60–80% stenosis (peak systolic velocity ratio 3.0) in the brachial artery, just distal to the arteriovenous anastomosis. At angiography the peripheral arteries could only be visualized with the fistula being occluded by external compression, but it confirmed the presence of a diaphragm-like stenosis of the brachial artery, distal to the anastomosis (Figure 1). The venous limb of the fistula was punctured and after pressure measurements were taken across the stenosis, sequential angioplasty to 3 mm, and then 5 mm was performed through a 5 French sheath. The runoff improved substantially and clinically the patient experienced resolution of the ischaemic symptoms. Case 2. The second patient is a 59-year-old male who had a left-sided 6 mm PTFE brachio-basilic arteriovenous shunt formed. One month after the procedure he started complaining of pain in the left hand at rest and developed patches of necrosis on the index and middle finger. An angiogram demonstrated shunting through the fistula with no demon-strable distal arterial flow. On fistula compression, an occlu-sion of the brachial artery above the elbow was revealed. A guidewire was readily passed through the occluding Fig. 1. Angiography showing presence of a diaphragm-like stenosis of the brachial artery.